What are
the issues for
unplanned
teen
pregnancy?
Dr Gillian Gibson, Service
Clinical Director, Epsom Day
Unit
Abortion Legislation in NZ overseen and
administered by the Abortion Supervisory Committee
Abortion is illegal in New Zealand unless statutory requirements met
TWO certifying consultants
Both doctors agree that continuing the pregnancy would result in serious danger to a woman’s mental or physical health.
• 98% of TOPs in NZ are for mental health indications
Governed by THREE laws:
Contraception, Sterilisation and Abortion Act 1977 (and amendments)
Crimes Act 1961
Care of Children Act 2004
New Zealand Parliament
rejects petition…but
recommendations for post
procedure care
In 2015 Hillary Kieft led a parental group petition for the government to approve mandatory parental notification for girls under 16 years of age
.
Care of Children Act 2004
Section 38 of the Care of Children Act 2004 determines that a young woman under the age of 16 can consent to an abortion but she must still go through the process outlined under the CS&A 1977.
“Gillick Competence”
Child 16 years or younger is able to consent to her own medical treatment without the need for parental permission.
TOP laws - Crimes Act 1961
Under 20 weeks
serious danger to life
serious danger to physical health
serious danger to mental health
any form of incest or sexual relations with a guardian
mental sub normality
foetal abnormality (added, July 1978 amendment)
Other factors that aren’t grounds but are taken into account
Extremes of age
Sexual violation (previously called rape)
Over 20 weeks
To save the life of the mother
To prevent serious permanent injury to the physical or mental health of the mother
Auckland Regional first trimester abortion service
Epsom Day Unit
Greenlane Clinical Centre
Regional- Auckland central, Counties, Waitemata
Total number > 3500 per annum
Medical and surgical abortion
Small increase in numbers 2017
Two visits the norm
Single operating theatre
Adolescent: 19 years and under
n=437
12% of total abortions at EDU
.
Demography of women having a first trimester termination of
pregnancy NWH 2017 Annual Clinical Report
0 5 10 15 20 25 30 35
≥40
35-39
30-34
25-29
20-24
≤19
Other
European
Other Asian
Indian
Pacific
Māori
Ag
eE
thn
icit
y
%
First trimester total
n=3648
<9 weeks
n=1287
35%
Medical
n=357
28%
Medical
10%
Surgical <9w
n=930
72%
>9 weeks
n=2361
65%
Surgical >9w
Surgical
90%
Epsom Day Unit
2017
Medical and surgical abortion
MTOP rate
< 9 weeks
only 28%
of eligible
population
First trimester
MTOP rate
is low
Medication abortion
RCOG:
“Method of
choice up to 9
weeks”
62% Abortion Statistics,
England and Wales:
2016
Early medical abortion at Dunedin
Hospital KAung and Cdevenish RANZCOG ASM poster
Retrospective 12 months 2017
500 TOPs per annum
280 referrals under 9 weeks gestation
243 of primary care and 37 self-referral
83 had STOP
176 underwent MTOP =
70% MTOP rate
21
96
49
10
0 50 100 150
<20
20-29
30-39
40-49
Ag
e r
an
ge
number
EDU MTOP rate among first trimester TOP by age and
ethnicity 2017 Annual Clinical Report Adolescents least likely to choose MTOP (Maori and pacific lowest uptake 4-6%)
Epsom Day Unit TI QI project 2015
< 9weeks
at referral
~70%
.
05
10
15
20
25
%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Gestation at referral
Gestation at referral March/April 2015
Medication abortion
up to 9 weeks gestation Mifepristone 200mcg 48hours later
misoprostol 800mcg
It is safe and acceptable to
complete the abortion at home
adequate support strategy and robust
follow-up arrangements
90% pass POC within 4-6 hours of misoprostol
bHCG follow up to check completion
Repeat medication or suction curettage in 5%
of cases
Haemorrhage <1% Failed abortion 0.4-0.8%
Must be given clear written advice about
how and when to seek medical advice during
the process of their termination
Medical vs Surgical abortion Advantages
MTOP
Sooner
Safer
Privacy
More natural
Less cost to
service
Depo or Implant
Disadvantages
MTOP
• Longer procedure (bleed +pain)
• Unpredictable
• Not available at weekend
• STOP can be same day
• May not have support at home
• Follow up BHCG
• 5% further treatment
• Failure rate similar to STOP
• Delay for IUCD insertion
EDU Investigations for first trimester abortion
Dating ultrasound:
To confirm IUP
To ensure viable ongoing pregnancy
Swabs: STI screen +/- BV
Blood test
First antenatal screening bloods
Including rhesus status
.
Models of care Telemedicine
Victoria Australia
Central referral service
“1800 My Options”
United Kingdom
“WoW” Women on Web
www.abortion.org.nz
nationalwomenshealth.adhb.govt.nz
abortion.org.nz>providers>auckland
Abortion Services in New Zealand
abortion.org.nz
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Method of contraception on discharge
ASC 2017-Auckland-all age groups
POST ABORTION
CONTRACEPTION(%)
LARCs 56
PILL 18
CONDOM 14
nil/other 15
TOTAL 100
LARCs used (%) Epsom Day Unit 2017
IUCD Copper 55
JADELLE 22
MIRENA IUS 12
DEPO INJ 11
TOTAL 100
How to better care for teens with unplanned
pregnancies?
Choice
Information resource
Range of entry points
Self or direct referral
Web based information
Confidential
Without parent’s knowledge
Telemedicine
Early referral
<63 days gestation for MTOP
Counselling pre- and post abortion
Non-judgemental
Depression & suicide teens at risk
Access
Community based
Model of care
Abortion Supervisory Committee recommendation for local DHB service
Legal requirements
Promote medical abortion
7 days a week
One day system for STOP
Improved outpatient facility
Transport options
ADHB taxi chits
Community health workers
Low cost
On site investigations
Quality
Culturally appropriate
Express manaaakitanga
Expert workforce
High school based health service
Family Planning Association
Nurses, social workers, General Practitioners
Specialist O & G training
Adult support
Parents may not be involved
What if there are complications
Contraception/sexual health
Funded Mirena IUS
Condom packs
Implants in stock